Form 15h - Declaration
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1
2FORM NO. 15H
[See section 197A(1C), and rule 29C(1A)]
Declaration under section 197A(1C) of the Income-tax Act, 1961 to be made by an individual who is of the age of sixty years or more claiming certain receipts without deduction of tax.
PART I
2. PAN of the Assessee
1. Name of Assessee (Declarant)
4. Assessment Year
3. Age
(for which declaration is being made)
5. Flat/Door/Block No.
6. Name of Premises
7. Assessed in which Ward/Circle
10. AO Code
(under whom assessed
8. Road/Street/Lane
9. Area/Locality
last time)
Area Code
AO Type
Range Code
AO No.
11. Town/City/District
12. State
13. PIN
14. Last Assessment Year
in which assessed
15. Email
16. Telephone No. (with STD Code) and Mobile No.
17. Present Ward/Circle
18. Name of Business/Occupupation
19. Present AO Code
(if not same as
above)
Area Code
AO Type
Range Code
AO No.
20. Jurisdictional Chief Commissioner of Income-tax or Commissioner of Income-tax
(if not assessed to
Income-tax earlier)
21.Estimated total income from the sources mentioned below:
(Please tick the relevant box)
Dividend from shares referred to in Schedule I
Interest on securities referred to in Schedule II
Interest on sums referred to in Schedule III
Income form units referred to in Schedule IV
The amount of withdrawal referred to in clause (a) of sub-section 2 of section 80CCA referred to in Schedule V
22.Estimated total income of the previous year in which income mentioned in Column 21 is to be included
23. Details of investments in respect of which the declaration is being made:
SCHEDULE-I
(Details of shares, which stand in the name of the declarant and beneficially owned by him)
Date(s) on which the shares were acquired
Class of shares & face
No. of shares
Total value of shares
Distinctive numbers of the shares
by the declarant (dd/mm/yyyy)
value of each share
SCHEDULE-II
(Details of the securities held in the name of declarant and beneficially owned by him)
Date(s) on which the securities were acquired
Description of securities
Number of securities
Amount of securities
Date(s) of securities (dd/mm/yyyy)
by the declarant (dd/mm/yyyy)
SCHEDULE-III
(Details of the sums given by the declarant on interest)
Name and address of the person to whom
Amount of sums
Date on which the sums were given on
Period for which sums were
Rate of interest
the sums are given on interest
given on interest
interest(dd/mm/yyyy)
given on interest
SCHEDULE-IV
(Details of the mutual fund units held in the name of declarant and beneficially owned by him)
Name and address of the
Number of
Class of units and face
Distinctive number of units
Income in respect of units
mutual fund
units
value of each unit
SCHEDULE-V
(Details of the withdrawal made from National Savings Scheme)
Particulars of the Post Office where the account under the National Savings Scheme
Date on which the account
The amount of withdrawal
is maintained and the account number
was opened(dd/mm/yyyy)
from the account
Signature of the Declarant
Declaration/Verification
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